Institutionen för folkhälso- och vårdvetenskap

Enheten för vårdvetenskap

Nurses' experiences of

caring for burn injured children in pain.

Author: Supervisor:

Andrea Olsson Khadija Innocencia

Yahaya-Malima

Dr. Clara Aarts

Examensarbete i Vårdvetenskap 15 hp Examinator:

Sjuksköterskeprogrammet 180 hp Dr. Pranee Lundberg

VT 2011

Sammanfattning:

Syfte: Syftet med studien var att ta reda på sjusköterskors erfarenheter av att vårda barn

på brännskadeenheten med smärta under omläggningar och vilka förhållanden och

hinder de uttrycker för att utföra sitt jobb inom smärtlindring Metod: Åtta

sjuksköterskor intervjuades med semistrukturerade öppna frågor på brännskadeenheten

för barn i Dar es Salaam. Intervjuerna spelades in med diktafon, transkriberades och

analyserades genom innehålls manifest. Resultat: Tre kategorier framkom genom

analysen, smärtskattning, smärtlindringsmetod och faktisk smärtbehandling.

Sjuksköterskorna uttryckte att smärtlindringsmetoderna och smärtskattningen de utför

fungerade utan anmärkning. De uttryckte att smärtskattningen fungerade som en

indikator på hur de brännskadade barnen uppförde sig och hur de påverkades under

dagliga omläggningar av sina brännskador. Resultaten från observationsstudien visade

att det inte fanns någon specifikt smärtskattningsinstrument som sjuksköterskorna

använde sig av, mera än ett kliniskt begrundande och erfarenhetsmässigt konstaterande

att barnen var smärtpåverkade under aktuell omläggning. Smärtbehandlingen som

användes mest frekvent var Panodil och sjuksköterskorna uttryckte sina rädslor för att

barnen skulle utveckla beroende till opiater om det användes i för stor utsträckning.

Slutsats: Smärtlindring är ett ämne som visar att sjuksköterskor som jobbar inom

området med brännskadade barn har goda kunskaper av smärtlindring. Däremot är det

rutinmässigt standardiserande av utsträckt smärtbehandling ett område som måste

belysas.

Nyckelord: omvårdnads erfarenheter, sjuksköterskor, brännskadade barn, smärta, Tanzania.

Abstract:

Aim: To illuminate how nurses working with burn injured children describe their

care for burn injured children in pain during dressing procedures and which

conditions and obstacles nurses express they are working under in order to proceed

with giving care. Method: Semi-structured qualitative interviews with eight nurses at

a pediatric burn ward in Dar es Salaam. Interviews were recorded, transcribed and

processed by manifest content analysis. Result: Three themes were derived and

identified as, pain assessment, pain management and pain treatment. Nurses

experienced the pain management as satisfactory and expressed pain assessment as

indication to how the burn injured children behaved and were affected upon daily

dressing of burn wounds. Results also showed from observations that there is no

specific pain assessment tool being used at the ward, more than the nurse’s clinical

eye and work experience at the dressing occasion. The main pain treatment used at

the ward was Panadol and nurses described their fear of children becoming tolerant

to opiates as reason why Panadol being used so extensively. Conclusion: This is a

topic that shows that nurses in dealing with pediatric burn injured patients have good

skills in pain management. However the routine use of pain treatment during

dressings as an extensive standard treatment needs to be illuminated.

Keywords: experience of caring, nurses, burn injured children, pain, Tanzania.

CONTENTS:

1. INTRODUCTION .............................................................................................................................. 5

1.1 Burn injuries in Tanzania ............................................................................................................... 5

1.2 Trauma of being burn injured ......................................................................................................... 6

1.3 Dressing of burn wounds ................................................................................................................ 6

1.4 Pain assessment ............................................................................................................................... 7

1.5 Pain management ............................................................................................................................ 7

1.6 Problem area ................................................................................................................................... 8

1.7 Aim of study ................................................................................................................................... 8

2. METHOD Burn injury background ................................................................................................. 9

2.1 Design ............................................................................................................................................ 9

2.2 Selection ......................................................................................................................................... 9

2.3 Data collection method ................................................................................................................... 9

2.4 Procedure ...................................................................................................................................... 10

2.5 Analysis ......................................................................................................................................... 10

2.6 Ethical consideration ..................................................................................................................... 12

3. RESULTS ...................................................................................................................................... 12

3.1 Pain assessment ............................................................................................................................. 14

3.2 Pain management .......................................................................................................................... 15

3.3 Pain treatment ............................................................................................................................... 16

3.4 Extent of burn injury and pain treatment prior to dressing of burn from observation .................. 17

4. DISCUSSION ................................................................................................................................ 18

4.1 Summary of results ....................................................................................................................... 18

4.2 Result discussion ........................................................................................................................... 18

4.3 Method discussion ......................................................................................................................... 20

4.4 Conclusion ................................................................................................................................... 22

5. REFERENCES................................................................................................................................ 22

APPENDIX I. INTERVIEW GUIDE ................................................................................................ 26

APPENDIX II. OBSERVATION GUIDE .......................................................................................... 27

APPENDIX III. LETTER OF CONSENT .......................................................................................... 28

5

INTRODUCTION:

1.1 Burn injuries in Tanzania

This thesis and the minor field study have been conducted in a hospital in Dar es

Salaam, Tanzania where large numbers of burn injured children are admitted to

hospitals in each year (Mbembati, Museru and Leshabari, 1999). Burn injured

children are a common patient category in Tanzanian hospitals due to the extent of

open fire cooking, along with the lack of preventative measures taken to keep burn

injuries at low numbers. Other reasons for children being admitted in hospitals

researchers from Tanzania found is because of the mentality of parents which is an

initial problem as to why children get burn injured. Over 50% of parents

participating in a study from Dar es Salaam hospitals have the idea that it is difficult

to control children and that accidents are unpreventable (Mbembati, Museru and

Leshabari, 1999). However there is evidence that parents suffer from feelings of

guilt, depression or post traumatic stress syndrome along with their child sustaining

burn injuries (Jansson and Gustavsson, 2005). Children under the age of three are the

most frequent age group of burn injured children where as older children are more

prone to have larger extents of their burn injuries supporting the fact that child safety

and prevention is needed (Serour, Gorenstein, and Boaz, 2008). Burn injured

children being admitted to pediatric burn wards need to be attended to accordingly

and ensured they get appropriate quality care for the time being hospitalized to

minimize future problems. There is more burn-prevention work to be developed

specifically for households with young children as children under six years still

sustain largely disproportional injuries (D’Souza, Nicholas, Nelson and McKenzie,

2009).

Problems related in burn injured children include post traumatic stress syndrome

(PTSD), burn injury dressing, infections related to burn injuries along with sufficient

or appropriate pain management where pain assessment is included.

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1.2 Trauma and being burn injured

Symptoms of trauma have been recognized in pre-school children together with

physiological reactivity. Children admitted to pediatric burn injury unit’s

demonstrated there was a relation between the smiles and vocalization frequency,

how much the children spoke and laughed after the burn injury. One of the measures

was by heart rate at 24 hours, after seven days and one month after the injury. The

higher the heart rate was at the time of measure the less the spontaneous smiles were.

The pain rating the child him or she did at 24 hours resulted in decreased frequency

in vocalization at one month post hospitalization (Stoddard et al., 2006). Pathways of

how the children’s symptoms of PTSD were expressed. One pathway concerned the

size of the burn together with the level of pain related to the burn along with a child’s

level of acute anxiety due to separation followed by the PTSD. Making the size of

the burn, level of pain estimated from the burn, related to the child’s level of acute

separation anxiety to PTSD. A second pathway showed the relation between burn

size and a child’s own measured level of acute dissociation at three months following

the burn to PTSD (Saxe et al., 2005).

1.3 Dressing of burn wounds

Children who have been admitted to hospitals often suffer from infections related to

their burn wounds and skin damage. Infections are a problem that can cause longer

hospitalization due to staphylococcus aureus and pseudomonas amongst other skin

organism that is commonly found contaminating granulation of burn wounds

(Hackett, 1971). This is a topic which is debated and there are many ways to carry

out dressing of burn wounds. When speaking of dressings the term itself covers

many treatments and can be sorted into categories: on admission, later treatment and

other procedures. Specifically these categories include everything from removal of

clothing, canulation for intravenous fluids, catheterization on admission to re-

dressing of burnt area, change of catheter in later treatment and cleaning of infected

areas for preparation for reception of upcoming skin grafts (Davies, 1971). To

prevent infections and long term scaring related to burn injuries the use of amnion

from new born children has been proved to have anti-inflammatory characteristics

7

and the need for antibiotics can be reduced (Ley-Chavez, Martines-Pardo, Roman,

Oliveros-Lonzano, and Canchola-Martines, 2003).

1.4 Pain assessment

Another aspect of suffering a burn injury is the pain experience and pain

management needed. Pain in a most subjective experience and when dealing with

children there are different skills to apply that differ from those used in adults when

performing pain assessment and pain management. Pain assessment for pediatric

patients can be carried out using different methods. Scales which are commonly used

when pain assessing pediatric patients are faces pain scales (FPS) where the primal

face of pain (PFP) offers explanation to the use and deficiency of face pain scales

and the face, leg, activity, cry, consolability scale (FLACC) (Schiavento, 2007). The

validity of these scales has been evaluated in different studies. Facial expressions of

a child when pain assessing, is considered to be a determinant and a highly reliable

cue when measuring child’s experience of pain (Schiavenato, 2007). These scales are

considered to be easily comprehensive for children (Silva and Thuler, 2008). The

Visual Analogue Scale (VAS) as well as the Faces Rating Scale (FRS) is two other

pain assessment tools that can be used interchangeably for evaluating acute

postoperative pain which is relevant in the skin grafting procedure (Fadaizadeh,

Emami and Samii, 2009). One consideration of using faces pain scales is that of

cross-cultural aspects. The ethnic background and culture may encourage or

discourage facial expressions and facial phenotypes and hence recognizing faces of

pain differently (Newman, et al., 2005). It is also concluded that children who are

undergoing surgery or painful procedures wish to have for them, comprehensive

information about the procedure, anesthesia and pain together with the complications

they might have ahead of them (Fortier et al., 2009).

1.5 Pain management

There are a number of methods to pain manage children with burn injuries of

different degrees. The use of topic analgesia Lidocain-Prilocaine cream (LPC) has

been studied with positive results for pediatric burn victims with burn degrees of the

first to third degree (Kargi and Tekerekoglu, 2010). The use of opiates in general for

burn victims is highly thought of, as many burn injured patients need skin grafting or

8

other surgery the use of intravenous opiates are often use for pre-operation pain

management (Dadure, Acosta and Capdevila, 2004). Opiates are also used in

inflammatory pain which is a common state of burn victims (Watterson, Howard and

Goldman, 2004). Methoxyflurane is also used to pain manage children with burn

injuries especially in general terms for burn dressing (Packer, 1972). The person who

gives pain management is a topic rarely discussed but brings light on to how children

experience pain and how parents acknowledges their child in pain prior to going to

the hospital (Spedding, Harley, Dunn and McKinney, 1999). Methadone compared to

morphine has shown to be a good substitute when dealing with the morphine tolerant

pediatric patient and leading to lower doses of needed analgesia (Williams,

Sarginson and Ratcliffe, 1998).

1.6 Problem area

Research have shown that children, especially children up to five years old are more

frequently victims of burn injuries also suffer psychological aspects related to the

burn (Membati et al., 1999). Not only is the burn a physically painful trauma such as

the pain related to daily dressings as is the child exposed to post traumatic stress

syndromes (Stoddard et al., 2006). There is a need to pain manage the individual

who is suffering from burn injuries in a scientifically supported manner along with

the nurse´s different experiences of a child in pain. The study was conducted in

Tanzania as this is one of the countries in the world where these problems arise and

are more frequent. The nurses at a city hospital in Dar es Salaam, work alongside

these problems when dressing burn injuries on a daily basis at a pediatric burn ward.

1.7 Aim of the study

The aim of the study is to illuminate how nurses working with burn injured children

describe their work with burn injured children in pain and which conditions and

obstacles nurses express they are working under in order to manage children’s pain

from a holistic view.

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2. METHOD

2.1 Design

The study is empirical and has a descriptive qualitative study design with semi-

structured interviews and observations. The design allows a phenomenon to be

studied and described in a matter that presents valuable reflections of individuals

(Polit, & Beck, 2008).

2.2 Sample

The sample group consisted of registered and enrolled nurses from the pediatric burn

ward at a hospital in Dar es Salaam, Tanzania. This ward is admitting children up to

the age of sixteen and treats all children with various burn degrees as well as patients

undergoing surgery such as skin grafting as a post-burn treatment. A selection

criterion for nurses to take part in the study was that they were enrolled or registered

nurses working in the ward for at least six months and English speaking. There were

approximately thirteen nurses both male and female working during the conduction

of the study. A number of ten nurses were requested to join and eight nurses were

included in the final interviews. The author limited herself to ten nurses considering

the interviews were transcribed by one relatively inexperienced person. The nurses

who did not consent to the study had reason of language skills and lack of

collaboration concerning work schedule and leave. The work experience variation of

the participating nurses varied from over one year to over ten years. All interviewed

nurses were female and the ages varied from 26 to 53 years of age.

2.3 Data collection method

Semi structured interviews were used. This method is commonly used and

considered to be revealing and to bring insight to what the individual experiences.

An interview guide (Appendix 2) was used in the field to bring background

information, experience of pain management and acknowledging the child in pain,

and work related problems with burn injured children on every day basis. The

10

interview guide was being based on the literature of interviewing methods and finally

established by the interviewer considering language differences and native spoken

language that might lead to misinterpretations (Dalen, 2008). The observation part of

the study took part during the daily dressing occasions of the children, following one

patient and nurse at the time prior to the interview. An observation guide to collect

background data (Appendix 1) was used to serve the purpose of recalling the type of

patient and the pain management scene. The observer used the FLACC-scale

(Schiavento, 2007) when observing the burn injured children undergoing dressings.

This scale is considered to be appropriate to use for objective measurements of pain

in children including children with cognitive impairment (Voepel-Lewis, Merkel,

Tait, Trzinka and Malviya, 2002).

2.4 Procedure

Before the study took place, permission had been granted by the ethical committee to

proceed with the study. The dean of school of nursing informed the head nurse at the

pediatric burn ward about the study. The head nurse of the pediatric burn ward

informed the nurses concerning the study. A letter of consent was handed out to all

nurses working in the pediatric burn ward stating all information in written version to

be signed if their wish was to partake in the study. A field study was undertaken by

the author prior to the interviews to get insight and understanding of the work and

management of the pediatric burn ward. The interview guide was tested prior to the

actual interview with one of the nurses to ensure its functionality as well as to test the

recording instrument being used. Data was collected on two consecutive days with a

number of four nurses per day. The interviews took place at the ward during the

nurse’s work hours in a secluded area to ensure privacy from fellow colleagues and

other hospital staff. Open ended questions were used and of a general matter. The

observation part of the study was based on ten patients, one for each nurse that was

first sought. Observations took place on the same day as the interviews were

conducted and took as long as the dressing of the child took which could vary in

time, pending on seize of each burn injury and level of healing process in the actual

burn injury being dressed. Observations were carried out prior to the interview with

the observer following the nurse in her daily routine and dressing of the children.

11

2.5 Analysis

Data was analyzed according to Qualitative content analysis in nursing research:

concepts, procedures and measures to achieve trustworthiness proposing qualitative

content analysis by using a manifest content analysis (Graneheim and Lundman,

2004). Through this type of manifest the text appears gradually whilst being worked

on. The text content proposed the informants different experiences. The parts of the

text which brought information in line with the aim of the study and questions asked

were taken out and constructed meaning bearing units being strictly quoted.

Condensed meaning units were used to shorten the text yet keep the substance of the

content. By abstracting the condensed meaning unit a code could be derived giving a

description of the meaning units’ content. Codes were then combined into sub-

themes and finally a theme. All steps of the content analysis was been done by the

author and over several weeks allowing reflection and consideration to various

interpretation possibilities and abstracting levels. To enable consensus the author

engaged a second colleague with more experience in the field to discuss the meaning,

interpretations and derived themes of the performed data analysis. Example of the

analyzing process is shown in table 1. Data gathered from the observations is shown

in table 3. This data was analyzed from the observation guide which was filled out by

the observer. This data shows the age, gender, percentage of burn, reason for burn

injury of the ten observed children together with the pain management used at the

occasion.

Table 1. Example of meaning units, condensed meaning units, sub-themes and

themes.

Meaning unit Condensed

meaning unit

Code Sub-theme Theme

“Sometimes it’s very difficult to

cope with these things…Because in

treating burn it takes very long

time…We don’t use to give

sedation…because we are afraid of

addiction. But after dressing we use

to give them analgesics like Panadol

and so forth. maybe when they come

It’s difficult to cope with

as treating burns take a

long time. We are afraid

of addiction so we don’t

use sedation. We give

Panadol after dressing or

Pethidine if they have

Difficulty in

finding

good pain

management

Appropriate

pain

management

Pain

manageme

nt

12

from operating theatre, for that pain

we are using to give them Pethidine

for maybe 8 hrs or 24 hrs if it

happens to have severe pain”

been to the operating

theatre to treat severe

pain.

“They use to be aggressive, crying,

too much crying and the

discomfort….When we are doing

dressing and in general we are

assessing that it is not normal or its

more than normal, so we can judge,

because we use it to use critical

thinking…that this is serious this is

not a joke”

The child’s actions and

expressions show if the

child is in pain. To asses

we compare with critical

thinking if it’s more than

normal

Knowing

how and

when to use

pain

assessment

Pain

assessment

skills

Pain

assessment

“… Panadol, we don’t use all the

time to give them drugs. Only when

they have pain and high

temperature… Sometimes we use to

do that of give them before dressing

but not usual… you may use wrong

to give them that treatment before

dressing because he will not be sad

maybe… So we wait and see, after

dressing we may see that one was

disturbing so it’s better to give… But

even if you can asses to go to the

ward just now …the way we are

dealing with them, they are ok now”

Panadol is what we use

the most, we think it

might be wrong to give

them analgesics if they

don’t need it.

Nurses

knowledge

of pain

treatment

Giving

appropriate

pain

treatment

Pain

treatment

“….children are stubborn, even you,

you feel that they are getting pain, but

nothing to do. We are trying to be

patient, and to let that situation in

order to complete the job smoothly.

We are trying to please them, you are

going to be cured, be don’t worried.

But they don’t even reasoning… But

after dressing, after a while they are

ok”

Children don’t cooperate

during dressing because

they are feeling pain at

the moment.

Recognizing

lack of pain

management

Lack of pain

management

Pain

manageme

nt

2.6 Ethical consideration

Permission to conduct the study was given from the ethical committee of Muhimbili

School of nursing in Dar es Salaam. The participants were informed that

participation was voluntary and that they at any given time could end their

participation of the study. It is of great importance that the informants’

confidentiality is secured so that no single identity can be withheld (The Northern

Nurse’s Federation, 2010). The interviews were hence cleared of identity and instead

replaced with a code number. After transcription work was done the interviews were

13

deleted. Observation demands respect of privacy and integrity of the patient. The

observer asked permission to stand by on dressing occasion from both nurse and

relative if being at the location. The children being observed were unnamed to secure

their identity.

3. RESULTS

Three main themes were derived under the analyzing phase of the interview study,

pain assessment, pain management and pain treatment shown in table 2. The themes

are discussed under sub-themes. The general background data analysis from the

observation study shown in table 3, showed that the average patient admitted to the

ward during ten observations of dressing occasions was 4.8 years old and ranged

from 1.5 to 9 years old and the average extent of the burn was estimated to 27

percent ranging from 9 percent to > 60 percent of full body. The gender of the

patients during these observations was five male and five females. Only one of these

patients received pain treatment prior to dressing shown in table 3.

Table 2. The study’s three themes and subthemes

Theme Sub-theme

Pain assessment Emotions and expressions of pain

assessment

Collaboration with patient and

caregiver

Pain management Collaboration with staff and

involvement of family members

Difficulty in giving appropriate pain

management

Under-treating pain

Hindrance of work at the ward

Pain treatment Nurses preference of choosing

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harmless pain treatment

Motivating pain treatment

3.1 Pain assessment

Pain assessment is a main part of the job when establishing a child's experience of pain, hence

to adequately treat a child's own pain. Pain is a subjective experience there for it is of great

importance that the nurse has emotions of empathy and great understanding of the issue.

3.1.1 Emotions and expressions of pain assessment

All the nurses had a view of pain assessment. The interviewed nurses’ experience of

pain assessing the burn injured children varied a great deal. There were detailed

descriptions of the children’s emotions, actions and effects of feeling pain. These

descriptions were in line with assessing according to the FLACC pain tool (Face,

Leg, Activity, Cry and Consolability). This is an observation tool with scores in each

area to enable assessing the child in a holistic view. The lesser described pain

assessments really did not follow any specific pain assessment tools. However all the

interviewed nurses expressed the same acknowledgements of the child’s expression

of tears, struggle and suffering during dressing.

“The children feel pain because the, the, the... wound is big…. Because

the head assessment is… is feeling crying, is feeling, you feel, you

feel…bad…. Mhm. Assessment to pain to the children is like to the face,

you feel crying ehm…..you feel warm (you =they)” (N3.)

“The child cries….they fight….they pee themselves. They are

hot…….sweating….ah things like that (laughs)” (N7.)

3.1.2 Collaboration with patient and caregiver

A few nurses at the ward taking part of the dressing experienced the pain assessment

being of importance to inform the patients and the mothers of the procedures which

15

was about to take place, regardless of the child’s daily experience of dressing

procedure. In order to get a good pain assessment nurses described the need for

cooperation and calm of the patient and relative.

“…Because we have many children and we are few so we don’t have

space, when you finish one you clean the table you continue. Also

mothers they are standby they want to be treated, everybody want…

ehe… everyone wants to be that one you are dressing (laughs) they

think that maybe the instrument can be finished and they, they can,

think they can stand without treatment, changing that dressing”. (N 4)

3.2 Pain management

Pain management in this case is viewed upon as a holistic way of caring for a patient

in pain admitted to the ward due to their burn injuries. To manage the patient there is

a need to consider how to care for the specific patient and which the best treatment

for the specific patient may be.

3.2.1 Collaboration with staff and involvement of family members

Nurses expressed routines and pain management according to their work situation.

From the gathered information the nurses expressed a satisfied opinion of their work

routine concerning pain management. They work along the side of a medical doctor

and interns at the ward and wishing to involve the patient and their relative.

“Treatment for pain, pain killer. The treatment, you must reassure the

mother what you are going to do. A nurse who was in duty she should be able

to know if the child she or he is in pain. And you give or administer the proper

drug which is it administered or prescribed by the specialist or intern Dr,

whichever is the administer” (N 1.)

3.2.2 Difficulties to give appropriate pain management

A few nurses expressed the difficulty to find an appropriate pain management

scheme and to cope with the situation accordingly, seeing the patient in pain. As

patients are there for a very long time suffering extensive injuries a number of nurses

16

expressed on several occasion that they are afraid of addiction to opiates of the

patients, leaving the child un-sedated on occasions when otherwise needed. Most

nurses rarely expressed urgent need for analgesics on dressing occasions or seeked

more administration from the doctors on the ward.

“Sometimes it is very difficult to cope with these things. Because in

treating burn it takes long time, it can take months…even a year if a

burn injury is big in percent. So….we don’t use to give sedation. We

don’t use sedation because we are afraid of addiction, to be addicted.

(N 4.)

Only one nurse expressed spontaneously she had not worked there for very long and

that she would like to give more pain treatment.

“Children you (they) feel pain because…because, because the wound is

bad. Mm, yeah I did not do this for a very long time. I like to give

medicine.” (N3.)

3.2.3 Under -treating pain.

Majority of the nurses expressed similar acknowledgements of children being

uncooperative during daily dressings due to the lack of appropriate pain management

resulting in nurses not being able to do their work in a wishful manner. Recognizing

the child in pain is to be considered as the child not being sufficiently pain managed

for the dressing occasion.

“…children are stubborn, even you, you feel that they are getting pain,

but nothing to do. We are trying to be patient, and to let that situation

in order to complete the job smoothly. We are trying to please them…

But they don’t even reasoning. But after dressing, after a while they

are ok (laughs)…” (N4.)

3.2.4 Hindrance of work at the ward.

A few nurses experienced the facility of the ward to be of hindrance as the children

suffered from the heat of the surroundings leaving the children impatient and stressed

17

with the situation prior to the dressing occasion as well as the work load for the

nurses with number of patients waiting in line for dressings.

“The children are crying, it is hot….and children are suffering…eh. I

want more time for information to patient…inform the mother and,

and…work together with…mmm” (N 7.)

“For example dressing or caring about one and a half to two hours for

one patient…ah…which is long time of hours. Which is long, tough job

because there is between fifteen to nineteen children” (N 1.)

3.3 Pain treatment

Pain treatment at the ward was available and prescribed by the physician or intern at

the ward. There was a variety of analgesics which could be used for different

situations. Panadol as a regular analgesic was used for fever or pain conditions in

general. Pethidine, opiates and non steroid analgesic drugs such as Diklofenak was

prescribed for serious pain conditions or when the pediatric has undergone surgery

recently.

3.3.1 Nurses preference of using harmless pain treatment

Pain treatment is shown by the study results to be generalized to Panadol. Most of

the nurses expressed few alternative analgesics to be used in the purpose to pain

relieve burn injured children specifically during the daily occurring dressing of

wounds. The use of stronger drugs or opiates was combined with the child having

undergone surgery such as skin grafting or recently being admitted to the ward. More

than half of the eight participating nurses expressed Panadol on several occasions as

the most appropriate analgesic to use as it has little side effects, expressing fear of

children being addicted to opiates.

“Panadol, as there is little side effects.” (N1.)

“Medicine to use for pain….ah …of pain...Paracetamol…. if you are

going to do…for doing the skin grafting…. Pethidine. If the wound is

clean you can use cream sometimes.” (N3.)

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3.3.2. Motivating pain treatment

The majority of nurses discussed the children's need for pain treatment and their

motivation why and when the child would need pain treatment. When comparing

data results shown in table 3 from the observation part of the study with the nurses’

transcribed interviews, the burn injured children did not receive more pain treatment

than observed and in line with the expressed frequency of the nurses.

“For me to say which one is the best…..I say Panadol ah…..we have

Panadol many times. Sometimes if the child is very much in pain….the

Dr may prescription Diklofenak….lakini (but in Swahili) for regular

patients who did not go to the operating theatre….we… ah… give them

Panadol.” (N8.)

“….after dressing we use to give them analgesics like Panadol and so

forth. But we are not giving them sedation…maybe when they come

from operating theatre, for that pain we are using to give them

Pethidine for maybe 8 hrs or 24 hrs., if it happens to have severe pain”

(N 4.)

3.4 Extent of burn injury and pain treatment prior to dressing from observation

This result is showing data collected from the observation part of the study which

was carried out prior to the interviews. On average the children’s summed up burn

extent injury was 27% from the observation study. The sustained injuries are caused

due to clothes catching on fire or being soaked in hot liquids. This leaves injuries

over torsos and genital areas in general as a result of clothes being centered on these

parts of the child’s body. This percentage should be taken in to consideration of the

individual’s age and size. Regardless of age and size the degree of burn should also

be accounted for, which can tell a lot of the pain the child will feel during dressing.

The observation study showed that in one case the one child with over 60% burn

injury was given pain treatment prior to the dressing.

Table 3. Observation study results.

19

Child age

in years

Gender Cause of sustained

injury

Percentage

of total

body burn

Pain

treatment

prior to

dressing

Pain

assessment

prior to

dressing

4 M Hot water scalding. 20 No No

5 M Burning garbage, fell in

to fire.

40 No No

2.5 F Scalding by boiling

beans, playing in

kitchen.

15 No No

1.5 M Scalding by milk, alone

in kitchen.

9 No No

9 M Epileptic seizure, fell in

to fire.

>60 Yes No

5 F Burning candle, clothes

on fire.

26 No No

7 M Playing with friends

next to open fire

cooking, clothes on

fire.

22 No No

4 F Scalding by hot

porridge.

18 No No

6 F Scalding by water. 30 No No

4 F Playing with matches to

burn grass, clothes on

fire.

18 No No

4.8 years

-average

27%

-average

4. DISCUSSION:

4.1 Summary of results

The children admitted and included in the study were under the age of ten and over

half had sustained injuries that were related to home bound injuries. Pain treatment at

20

the pediatric burn ward included Panadol on regular occasions but not frequently

prior to dressings. Stronger drugs such as Pethidine was more commonly used related

to skin grafting procedures or when extensive pain relief was considered necessary

due to severity of burn injury. The analysis of the interviews resulted in three themes,

pain assessment, pain management and pain treatment under which the specific

objectives could be answered.

The nurses at the burn ward expressed assessment skills that cannot be compared

with a specific pain assessment tool. The results expressed the nurse’s experiences

of pain management as well as their work routines concerning pain management.

Nurses’ experience having satisfying pain management skills and work according to

their set ward routines. Further the observations showed that the nurses did not use

any pain assessment tools before and during burn dressings and the children were not

pain treated on most occasions prior to their upcoming dressing. The observation

part of the study showed that children regardless of degree of burn did not receive

pain treatment in majority of the ten observed dressing occasions.

4.2. Result discussion

4.2.1 Pain assessment - Knowing the child is in pain.

The nurses experienced that knowing the child is in pain is a skill that they learn

from experience working in the field. The use of pain assessment tools such as VAS,

Bieri faces pain scale, FRS all of which have been presented in the introduction and

which one was preferred by nurses in establishing the child’s level of pain was

unclear as during interviews the nurses did not specifically express their own

preference of pain assessment tool. However the children themselves clearly

expressed their pain during dressing. A study has shown that a child’s self report is a

reliable pain assessment tool, stating the fact that any valid pain assessment tool is

necessary to use when pain assessing children in any case (Bulloch and Tenenbein,

2002). Observation did not show any use of pain assessment tools resulting in a

documented score, from the observations the nurses did not use any pain scales

accordingly. Judging from observations it seems most likely that the nurses use their

own type of pain assessment. Of which the results can be compared to the FLACC-

21

scale if that would that have been used. Using the FLACC-scale can be supported as

valid tool even when pain assessing cognitive impaired children (Voepel et al.,

2002). It has been discussed that pain assessment motivation may vary to a greater

extent than predicted when a person is pain assessing others. Meaning that some pain

assessments might be under scored or leaving a patient insufficiently pain managed

due to the pain assessing persons own beliefs of pain and motivation to follow

through on pain assessment and management. Although more research in the subject

is required (Franck and Bruce, 2009). The author however finds it interesting to find

that the ability and motivation might actually be a matter of culture, personality and

skills combined.

4.2.2 Pain management - Treating pain from a holistic view in burn injured children.

Nurses expressed little use of analgesic drugs in general, although they named a

variety. The variety of pain treatment and ways of administering pain treatment for

burn injured children is broad and are effective and proven to suit their purpose such

as morphine tablets, morphine administered intravenously and also topically

(Watterson et al., 2004). The main objective is to individualize pain assessment and

the given pain treatment to ensure adequate pain treatment is given the specific child

to soothe their condition to the fullest extent possible. It seems to be a matter of

opinion from the interviewed that the child apparently will manage and cope with the

burn dressing under the existing circumstance and that nurses more often treat pain

after dressing if the child still complains or suffer from pain. The results from this

study shows that more work is needed to pain manage children at the pediatric burn

ward, and the study can be used to illuminate the lack of administered pain treatment

to improve the situation for children undergoing painful daily dressings.

4.2.3 Problems in proceeding with daily dressing of burn injured children.

Nurses in the pediatric burn ward repeatedly expressed the patient’s lack of

cooperation during dressing occasions as being a hindrance in their work process.

This indicates that the burn injured children are insufficiently pain managed prior to

the dressing occasion. A child undergoing dressing of their burn injuries may

experience the situation so stressful that it possibly could disturb their biological

stress system leading to inherent temperamental traits (Stoddard et al, 2006). It is

22

already proven that burn injured children suffer from PTSD. This supports the fact

that burn injured children should be sufficiently pain managed in all aspects of their

condition, referring to burn dressings being a general term for what the burn injured

patient has to undergo (Davies, 1971). Supporting the fact that children suffer from

distress and anxiety related to dressing of the sustained burn injury as well as this

being state can prolong the time needed for the burn management procedure. It is

also shown that children can be distracted by games during dressing in some

situations leading to lower pain scores (Debashish, Grimmer, Sparnon, MacRae and

Thomas, 2005).

4.2.4 Pain treatment - The best pain management for burn injured children.

The study showed that the nurses at the pediatric burn ward had good facilities to

care for children suffering from burn injuries in the sense of stating availability of

appropriate pain treatment. The theoretical practice of individualizing pain treatment

should lead to a number of analgesic methods to be used. Such as opiates in general,

topical analgesic treatment or peripheral analgesics. Considering the majority of

nurses expressed that Panadol being the best pain management for burn injured

children leaves a lot of room for improvement in the area. The nurses expressed fear

of addiction appearing in children as one of the reasons to their preference of

Panadol. Pain management when administered, assessed and monitored properly

leaves little indication to assume the burn injured child will be showing tolerance

immediately. Meaning there is a number of options to turn to and precautions to take

should a child show signs of tolerance to opiates. The use of morphine can for

example be exchanged with methadone to reduce unwished for side effects (Williams

et al., 1998).

4.2.5 Observation study

The observation part of the study was valuable for the author in writing the thesis.

The observations served as background data to recall the dressing situation when

later interviewing the nurses. Although the author did consider some ethical aspects

of conducting observations as having an observer during dressing occasion can be of

conflict of ethical aspects. Having an observer also might affect the behavior of

23

children undergoing dressing as well as the nurses paying more attention to the work

situation, feeling uncomfortable or simply being distracted.

4.3 Method discussion

4.3.1 Credibility - how reliable are the results in relation to the objectives of the study.

Credibility was established due to the nurses answering the same questions. This

gave all the nurses the same opportunity to express their views on each question

asked. Semi-structured qualitative interview open ended questions were used since

this reveals the informants own experience (Polit, & Beck, 2008). Communicative

validity may be discussed since the author is not a trained interviewer as a

profession, leaving more room for improved interview skills or methods. The nurses

who took part in the interviews may have experienced the situation stressful

considering their workload. However nurses were not extracted from their work

situation and the author gave the nurses time to gather information and themselves

prior to the interview session.

Since the interview questions were of a general matter and open ended the nurses

seemed at times unsure of how to answer, this leaves consideration for experienced

language difficulties. With more specific question the informants may have been able

to express themselves more or even the use of a questionnaire form so the nurses

could take the questionnaire home and reply with written answers. The internal

validity of this matter can be questioned. As the author did not execute participant

self control of the interview material to avoid or be able to correct misunderstandings

on behalf of the author. The questions used however gave valuable information as of

how nurses experience pain management and their feelings at the working moment

extending credibility to the study.

From the discussion of the three derived themes it became clear as to which themes

fell in to the aim of the study in a natural manner. Something which pleased the

author as it was not predicted. The nurse’s description of knowing the burn injured

child is in pain fell in to the pain assessment theme. Nurses describing the objectives

concerning treating pain in burn injured children and problems in proceeding with

24

daily dressing of burn injured children underwent the theme of pain management.

Pain treatment as one theme covered the objective of what nurses considered to be

the best pain treatment. The themes illuminate the core of pain management as a

holistic aspect, and support the ways of scientifically proven methods of pain

management.

4.3.2 Dependability - how reliable is the conclusion compared to the extracted material.

Dependability was reached through showing a clear line throughout the text to the

derived themes. The author chose to proceed with a manifest content analysis to

identify similarities and differences in the informant’s opinions (Graneheim and

Lundman, 2004). The analysis process is accounted for via the meaning units,

condensed meanings and way of abstractions in text and examples shown in table1.

Every step of the analysis process has been reflected upon concerning interpretation

possibilities and abstraction levels. Reaching the codes and themes are then

considered to help strengthen the analysis result. Validity in this sense is considered

to be reached as the author took precautions during the analyzing part before stating

the codes, themes and sub-themes. This was a precaution taken since the author was

inexperienced compared to other experienced interviewers who might reach

abstraction levels faster.

4.3.3 Transferability - in what way can the results be used.

Data collected from the study was withheld from ten observations and eight

interviews. All interviews were used in the result. No particular exclusion needed to

be done as the author depended on all the informants whom could be used in terms of

the informant’s language skills and available staff that suited the selection criteria.

The informants limited language skills and limited variation of work experience

ranging from over one year to ten is a limit in itself to illuminate the specific

objectives from a variety of experience.

As a qualitative study it cannot be generalized over all pediatric burn wards in

Tanzania as other wards might have different solutions to their dealing with pain

management. On the other hand the study illuminates how the nurses working at

Muhimbili university hospital and the pediatric burn ward experience their given

pain management. The study can be of clinical relevance when looking at extended

25

development and educational matters for the staff. It can be of interest to extend the

study to see whether there are more aspects to the lack of pain management in

general being used at the pediatric burn ward.

4.4 Conclusion

Pain management among nurses caring for burn injured children is a subject that

needs to be paid more attention to. The nurses express both experience and

knowledge of how to assess pain and manage pain. Yet there is a lack of routines to

fulfill the duty of ever existing need for pain management.

4.4.1 Nursing implications

These findings provide good reason the potential role for interventions to be carried

out in the purpose to improve the dressing occasions for the burn injured children

concerning their experienced pain as well as improving the work situation for the

nurses.

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Appendix 1.

Observation guide

Patient data: For background information only

Ward: Date: Time:

Patient/Gender: Age:

Type of burn injury: degree of injury

Cause of injury: Time since injury and time spent in hospital

Analgesic method:

Time for analgesia:

Time of dressing burn wound:

Pain evaluation:

Nurse at dressing occasion uses pain evaluation tool Yes/No

Patient expresses pain (observer uses FLACC) Yes/No

Nurse acknowledges patients pain. (i.e. talks to patient, gives analgesia) Yes/No

observation notes: (short notes to remember the occasion)

30

Appendix 2.

Interview guide: Open ended questions of a general matter with a nurse during

approximately 20 min.

Background fact on nurse:

Enrolled or registered nurse.

How many months or years experience at the pediatric burn ward.

How would you like to provide good pain management for or treat children with burn

injuries with pain? e.g

- What is your experience of treating pain in children?

- Which is the best pain treatment for burn injured children?

- How do you know the child is in pain? In your opinion do you feel you have a good

assessment tool?

- What kind of problems do you meet in your daily work with burn injured child patients?

31

Appendix 3.

Participant information and consent form

Study regarding nurse’s experience of pain management in caring for burn injured children.

My name is Andrea Olsson and I am a third year nursing student from Uppsala University in

Sweden. Muhimbili University of Health and Allied Sciences and Uppsala University have a

co-operation offering student exchange. I am writing my thesis in the period September

through December. I will conduct a small study entitled; Nurses experience of pain

management in caring for burn injured children. Permission for the study is given by the Dean

of school of nursing.

Purpose of the Study

The aim of the study is to investigate how nurses at Muhimbili University Hospital in Dar Es

Salaam, Tanzania experience and work with pain management of burn patients at a paediatric

ward.

Participants

Ten nurses at Muhimbili University hospital in Dar es Salaam will be asked to voluntary

participate on one occasion each.

What Participation Involves

Participants will be asked questions about their experience of caring for paediatric patients

with pain due to burn injuries. The interview will be recorded with a tape recorder and the

information used to write a study report. The interview will take approximately 20-30

minutes. The interviewer and nurse will agree on a appropriate time related to a patient care

situation for reflection and interview.

Participants full rights

Participation in this study is voluntary. Participants are free to withdraw from the study

without expressing their reason. I will be sincerely grateful for all participation however.

32

Confidentiality

I will assure that strict confidentiality will be assessed for the study. No names will be

mentioned or left traceable in the study. All documents will be kept among me and my

supervisor in Tanzania and Sweden.

Benefits

There will be no economic benefit to the voluntary participants in this study. However, the

results of the study might be of interest for nurses involved in their future work as a health

care professionals dealing with pain management. A copy of the finished report will be sent to

the participants either by mail or email and the school of nursing.

Who to Contact

Voluntary nurse participants with questions concerning this study are welcome to contact me

at site or via e- mail:

Andrea Olsson; olssonandrea@hotmail.com

Consent to participate in a research project:

Participant agrees………………………… Participant does NOT agree ……………….........

I, _________________________________have read the contents in this form. My questions

have been answered. I agree to participate in this study.

Signature of participant_________________________________

Signature of researcher__________________________ Date of signed consent:

33